Criteria
Coverage is subject to the specific terms of the member's benefit plan.
Federal Employee Program members (FEP) should check with their Retail Pharmacy Program to determine if prior approval is required by calling the Retail Pharmacy Program at 1-800-624-5060 (TTY: 1-800-624-5077). FEP members can also obtain the list through the www.fepblue.org website.
Tisotumab vedotin-tftv (Tivdak) may be considered medically necessary in individuals 18 years and older for the following:
- As treatment of individuals with recurrent or metastatic cervical cancer with disease progression on or after chemotherapy; or
Compendia Sources
Tisotumab vedotin-tftv (Tivdak) may be considered medically necessary for treatment of any of the current category 1 or 2A NCCN recommendations.
The use of tisotumab vedotin-tftv (Tivdak) for all other indications not listed in this policy is considered experimental/investigational and therefore non-covered because the safety and/or effectiveness cannot be established by the available published peer-reviewed literature.
Procedure Codes
